10.2 Fraud Investigation, Payment Recovery, and Sanctions

Lead Agencies must have the necessary controls to identify fraud and other program violations to ensure program integrity. Program violations can include both intentional and unintentional client and/or provider violations, as defined by the Lead Agency. These violations and errors, identified through the error-rate review process and other review processes, may result in payment or nonpayment (administrative) errors and may or may not be the result of fraud, based on the Lead Agency definition. 10.2.1 Strategies used to identify and prevent program violations Check the activities the Lead Agency employs to ensure program integrity, and for each checked activity, identify what type of program violations the activity addresses, describe the activity and the results of these activities based on the most recent analysis. a. [ ] Share/match data from other programs (e.g., TANF program, Child and Adult Care Food Program, Food and Nutrition Service (FNS), Medicaid) or other databases (e.g., State Directory of New Hires, Social Security Administration, Public Assistance Reporting Information System (PARIS)). i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice:: b. [ ] Run system reports that flag errors (include types). i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: c. [ ] Review enrollment documents and attendance or billing records. i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: d. [x] Conduct supervisory staff reviews or quality assurance reviews. i. [x] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Invoices are reviewed prior to entry into the data system to prevent program violations. Supervisors are required to review the eligibility determinations of all new workers, and are required to review a sample of experienced workers' eligibility determinations on a monthly basis. ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Invoices are reviewed prior to entry into the data system to prevent program violations. Supervisors are required to review the eligibility determinations of all new workers, and are required to review a sample of experienced workers' eligibility determinations on a monthly basis. iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: e. [ ] Audit provider records. i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: f. [x] Train staff on policy and/or audits. i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [x] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: Supervisors are required to review the eligibility determinations of all new workers, and are required to review a sample of experienced workers' eligibility determinations on a monthly basis. They use the results of these reviews to determine training needs for each individual worker. In addition, they use these results to plan topic areas for case manager conferences. iii. [x] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: Supervisors are required to review the eligibility determinations of all new workers, and are required to review a sample of experienced workers' eligibility determinations on a monthly basis. They use the results of these reviews to determine training needs for each individual worker. In addition, they use the results of these reviews to plan topic areas for case manager conferences. This process has led to the Lead Agency's low error rate. g. [ ] Other. Describe the activity(ies): i. [ ] Intentional program violations. Describe the activities, the results of these activities, and how they inform better practice: ii. [ ] Unintentional program violations. Describe the activities, the results of these activities, and how they inform better practice: iii. [ ] Agency errors. Describe the activities, the results of these activities, and how they inform better practice: 10.2.2 Identification and recovery of misspent funds Lead Agencies must identify and recover misspent funds that are a result of fraud, and they have the option to recover any misspent funds that are a result of unintentional program violations or agency errors. a. Identify which agency is responsible for pursuing fraud and overpayments (e.g., State Office of the Inspector General, State Attorney): Office of the Inspector General-West Virginia Department of Health and Human Resources. b. Check and describe all activities, including the results of such activity, that the Lead Agency uses to investigate and recover improper payments due to fraud. Consider in your response potential fraud committed by providers, clients, staff, vendors, and contractors. Include in the description how each activity assists in the investigation and recovery of improper payment due to fraud or intentional program violations. Activities can include, but are not limited to, the following: i. [x] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: Lead agency will seek to enter into a repayment agreement with the client allowing for regular payments to be made until the total is recovered. The amount is only recovered if due to intentional fraud. ii. [ ] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: iii. [x] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: Lead agency will seek to enter into a repayment agreement with the client allowing for regular payments to be made until the total is recovered. There have been zero fraud referrals since the last state plan cycle. As such, there are no results to report. iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [ ] Other. Describe the activities and the results of these activities: c. Does the Lead Agency investigate and recover improper payments due to unintentional program violations? [x] No. [ ] Yes. If yes, check and describe below any activities that the Lead Agency will use to investigate and recover improper payments due to unintentional program violations. Include in the description how each activity assists in the investigation and recovery of improper payments due to unintentional program violations. Include a description of the results of such activity. i. [ ] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: ii. [ ] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: iii. [ ] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ] Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [ ] Other. Describe the activities and the results of these activities: d. Does the Lead Agency investigate and recover improper payments due to agency errors? [x] No. [ ] Yes. If yes, check and describe all activities that the Lead Agency will use to investigate and recover improper payments due to agency errors. Include in the description how each activity assists in the investigation and recovery of improper payments due to administrative errors. Include a description of the results of such activity. i. [ ] Require recovery after a minimum dollar amount of an improper payment and identify the minimum dollar amount. Describe the activities and the results of these activities based on the most recent analysis: ii. [ ] Coordinate with and refer to the other State/Territory agencies (e.g., State/Territory collection agency, law enforcement agency). Describe the activities and the results of these activities based on the most recent analysis: iii. [ ] Recover through repayment plans. Describe the activities and the results of these activities based on the most recent analysis: iv. [ ] Reduce payments in subsequent months. Describe the activities and the results of these activities based on the most recent analysis: v. [ ] Recover through State/Territory tax intercepts. Describe the activities and the results of these activities based on the most recent analysis: vi. [ ]Recover through other means. Describe the activities and the results of these activities based on the most recent analysis: vii. [ ] Establish a unit to investigate and collect improper payments and describe the composition of the unit. Describe the activities and the results of these activities based on the most recent analysis: viii. [ ] Other. Describe the activities and the results of these activities: e. What type of sanction will the Lead Agency place on clients and providers to help reduce improper payments due to intentional program violations or fraud? Check and describe all that apply: i. [x] Disqualify the client. Describe this process, including a description of the appeal process for clients who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: This process applies to both clients and providers: Supervisors are responsible for negotiating repayment schedules with providers and/or clients and completing a Repayment Agreement to include the amount to be recovered, the period of recovery the monthly recovery amount, and the procedure for repayment. If intentional misrepresentation may have occurred and the provider /client remains active, it is recommended that the CCR&R worker try to collect the payment in full. If this is not feasible, it is suggested that the R&R worker request that the client or provider be asked to repay the amount in monthly installment payments of approximately 10% of the amount due. Payment schedules should be sufficient to recover the amount due within a reasonable time period but should not pose an undue hardship on a client. The amount of payment should not exceed living costs. Payments must be made by money order. If a payment is more than forty- five (45) days late, the entire unpaid balance becomes due and must be paid in full. Failure to repay the requested amount shall result in case closure for clients or denial of participation in the certificate system for child care providers. Client services will not be reinstated until full payment is received. The West Virginia Public Welfare Law and subsequent administrative actions have guaranteed and applicant for or recipient of Social Services the right to a hearing concerning and action taken by the Department of Human Services. Every child care client and provider have the right to request a hearing concerning action taken by the Department or CCR&R workers. The State Board of Review is designated by State Law as the body through which a client or provider imay present his/her case to a higher authority. The State Hearing Officer is an impartial official who has not been directly involved in any determination of the action in question. ii. [x]Disqualify the provider. Describe this process, including a description of the appeal process for providers who are disqualified. Describe the activities and the results of these activities based on the most recent analysis: This process applies to both clients and providers: Supervisors are responsible for negotiating repayment schedules with providers and/or clients and completing a Repayment Agreement to include the amount to be recovered, the period of recovery the monthly recovery amount, and the procedure for repayment. If intentional misrepresentation may have occurred and the provider /client remains active, it is recommended that the CCR&R worker try to collect the payment in full. If this is not feasible, it is suggested that the R&R worker request that the client or provider be asked to repay the amount in monthly installment payments of approximately 10% of the amount due. Payment schedules should be sufficient to recover the amount due within a reasonable time period but should not pose an undue hardship on a client. The amount of payment should not exceed living costs. Payments must be made by money order. If a payment is more than forty- five (45) days late, the entire unpaid balance becomes due and must be paid in full. Failure to repay the requested amount shall result in case closure for clients or denial of participation in the certificate system for child care providers. Client services will not be reinstated until full payment is received. The West Virginia Public Welfare Law and subsequent administrative actions have guaranteed and applicant for or recipient of Social Services the right to a hearing concerning and action taken by the Department of Human Services. Every child care client and provider have the right to request a hearing concerning action taken by the Department or CCR&R workers. The State Board of Review is designated by State Law as the body through which a client or provider may present his/her case to a higher authority. The State Hearing Officer is an impartial official who has not been directly involved in any determination of the action in question. iii. [ ] Prosecute criminally. Describe the activities and the results of these activities based on the most recent analysis: iv. [x] Other. Describe the activities and the results of these activities based on the most recent analysis: There have been zero fraud referrals since the last plan cycle. As such, there are no results to report. Appendix 1: Lead Agency Implementation Plan The Appendix will be available for Lead Agencies to use in CARS after the Plan approval letter is issued. For each non-compliance, Lead Agencies must describe the following: • Action Steps: List the action steps needed to correct the finding (e.g., update policy manual, legislative approval, IT system changes, etc.). For each action step list the: o Responsible Entity: Indicate the entity (e.g., agency, team, etc.) responsible for completing the action step. o Expected Completion Date: List the expected completion date for the action step. • Overall Target Date for Compliance: List date Lead Agency anticipates completing implementation, achieving full compliance with all aspects of the findings. (Note: Compliance will not be determined until the FFY 2025-2027 CCDF Plan is amended and approved). Appendix 1: Form [Plan question with non-compliance and associated provision will pre-populate based on preliminary notice of non-compliance] A. Action Steps for Implementation B. Responsible Entity(ies) C. Expected Completion Date Step 1: Step 2 (as necessary): [Additional steps added as necessary] Overall Target Date for Compliance: